Health insurance companies are expanding their coverage of bariatric surgery amid rising demand for pricey new weight loss drugs.
Geisinger Health Plan and Blue Cross and Blue Shield carriers in Massachusetts, Michigan and Vermont are among those easing access to bariatric surgery over the past year as patients seek medicines such as Novo Nordisk’s Wegovy and Ozempic and Eli Lilly's Trulicity that can cost about $1,000 a month in perpetuity.
Related: Insurers, PBMs restrict access to weight loss drugs as demand soars
Insurers say changes such as lifting prior authorization requirements and covering bariatric surgery for more conditions are merely the result of regular reviews and not a response to these new medications, known as glucagon-like peptide 1, or GLP-1, agonists.
“Our policies don't prioritize bariatric surgery over GLP-1s. The decision between a GLP-1 and bariatric surgery is not our decision. That's a decision made by the patient with the consultation of their physician,” said Dr. Jim Grant, chief medical officer for Blue Cross Blue Shield of Michigan.
But some providers and policy experts observe that this more favorable approach to bariatric surgery coincides with the introduction of expensive drugs most patients must use indefinitely to sustain clinical benefits, at great cost to health insurers. Putting patients under the knife is comparatively cheaper, said James Chambers, a professor at Tufts Medical Center who studies insurance coverage of GLP-1s.
“This is an example of how a new technology is forcing the healthcare system to reevaluate existing technologies, not just in terms of the cost, but also the value,” Chambers said.
Bariatric surgery is a catch-all term for several procedures, such as gastric bypass or gastric sleeve, which utilize different methods to shrink stomachs and substantially alter how and what patients eat. Multiple studies have shown these interventions to be the most effective weight loss treatments for the one in three U.S. adults with obesity.
Yet adoption remains low: An estimated 228,000 people undergo bariatric surgery in the U.S. each year, or 1% of the eligible population, according to a study the journal Surgery for Obesity and Related Diseases published in 2019. High costs and lack of insurance coverage are among the reasons, Temple University researchers wrote in the journal.
In 2022, the American Society for Metabolic and Bariatric Surgery updated its clinical guidelines to expand the recommended patient population based on new evidence of efficacy and to encourage better insurance coverage, said Dr. Marina Kurian, the director of New York Minimally Invasive Surgery who serves as president of the physician organization. On average, bariatric surgery costs $17,000 to $26,000, according to the medical society.
"In two years, the costs are equivalent (to use of GLP-1s). The benefit, though, is that with surgery there's greater weight loss and greater reduction in comorbid conditions,” Kurian said.
Insurers making coverage calculations could also be banking on prospective patients not completing the rigorous processes hospitals require to be cleared for bariatric surgery, thereby saving their health plans money, said Dr. Neil Floch, director of bariatric surgery for Connecticut-based Yale New Haven Health System's Greenwich Hospital.
Like many health systems, the Yale University affiliate requires prospective bariatric patients to consult with nutritionists, psychiatrists and exercise physiologists, and to attend educational seminars before approving them for the surgery, Floch said. A nationwide physician shortage also presents a obstacle, Floch said.
Insurers are "probably seeing that it's harder to go and get bariatric surgery, and politically, they want to offer something. So why not do the thing that has a bigger barrier?” Floch said.
Blue Cross Blue Shield of Michigan eliminated prior authorization requirements for bariatric surgery in September. A month later, the nonprofit insurer enacted more stringent prior authorization and step therapy requirements for GLP-1s.
“We saw, at the end of the day, that we were making people go through unnecessary hoops for bariatric surgery,” Grant said. “Why make our physicians and our members go through unnecessary hassles?"
The insurer does not anticipate the change in policies to provide a boost to bariatric surgery, for which it processes approximately 6,000 claims a year, Grant said.
Geisinger Health Plan, meanwhile, has noticed a slight decrease in its bariatric surgery claims since the GLP-1s debuted, Chief Medical Officer Dr. John Bulger said. The nonprofit insurer, a unit of Danville, Pennsylvania-based Geisinger Health, widened bariatric surgery coverage to include additional conditions while implementing tougher requirements for GLP-1s starting this year.
"If you have patients who benefit from GLP-1s, but can't tolerate them for whatever reason, they may be great candidates to have bariatric surgery," Bulger said. “There are a lot of patients that don't tolerate them and, in the end, whether people will continue to take them or not remains to be seen. People start them and stop them.”
Medical device companies such as Johnson & Johnson, Medtronic and Intuit Medical Products that make gastric bands, balloons and other bariatric surgery equipment likewise have reassured investors that new weight loss treatments will boost their bottom lines as more people become aware of obesity as a medical condition and evaluate their treatment options.
“When we talk to bariatric surgeons, many of them comment on the fact that they could see a tailwind for bariatric surgery down the road,” Johnson & Johnson CEO Joaquin Duato said during a call with investors in October. “Many of the patients—about 30% of them—are not going to be tolerating these medications. There would be another funnel for our bariatric business.”
More primary care doctors are partnering with surgeons to create integrated treatment plans, said Kristal Hartman, board chair of the Obesity Action Coalition, a patient advocacy group financially supported by Novo Nordisk, Eli Lilly, Geisinger, the American Society for Metabolic and Bariatric Surgery, as well as other drugmakers, device companies and providers. Hartman has undergone bariatric surgery and uses GLP-1s to manage her weight and other conditions. The combination has helped her lose 150 pounds, she said.
"We already have data that shows the surgery has shown to be successful," Hartman said. "Insurers may be thinking, 'We should start reducing some of the barriers to bariatric surgery while we work out everyone in the world thinking that suddenly 40% of America is going to be put on a $1,300 a month GLP-1 drug.'"
